EFFECT OF SELECTED YOGIC PRACTICES ON CLINICAL VARIABLE MORNING

STIFFNESS AMONG ANKYLOSING SPONDYLITIS

Author’s

1. Sujay Prakash.R, Ph.D Scholar- Yoga, Centre for Yoga Studies, Annamalai University,
Tamilnadu, India

2. Dr.G.Santhosh Kumar, Research Supervisor, Physical Director, Department of

physical Education, Rajah Serfoji Government Arts College - Thanjavur, Tamilnadu,
India.

3. Prof.K.Deepla, Co-Guide, Chairman – BOS in Physical Education, University College

of Physical Education, Osmania University, Hyderabad.

4. Dr Sarath Chandra Mouli Veeravalli, Co-Guide, Department of Rheumatology and

Clinical Immunology, KIMS Hospitals, Secunderabad, Telangana.

Abstract

The purpose of the study was to find out the effect of selected yogic practices on clinical
variable among ankylosing spondylitis. The study was conducted on 60 ankylosing spondylitis
patients. Totally two group’s namely experimental group I and control group consisting of 30
ankylosing spondylitis patients in each group who underwent twelve weeks of yoga practices
whereas the control group did not undergo any type of training. The morning stiffness was
measured before and after the experimentation using the standardized test to measure the clinical
investigations and analyzed by Analysis of Covariance (ANCOVA) and it was concluded that
the yogic practices had significant (P < 0.05) effect on the morning stiffness.

Key words: morning stiffness, asana, pranayama, Ankylosing spondylitis, yoga, yoga therapy,
yoga nidra, sukshma vyayama
Introduction

Ankylosing spondylitis is a form of chronic inflammation of the spine and the sacroiliac
joints. The sacroiliac joints are located at the base of the low back where the sacrum (the bone
directly above the tailbone) meets the iliac bones (bones on either side of the upper buttocks) of
the pelvis. Chronic inflammation in these areas causes pain and stiffness in and around the spine,
including the neck, middle back, lower back, and buttocks. Over time, chronic inflammation of
the spine (spondylitis) can lead to a complete cementing together (fusion) of the vertebrae, a
process referred to as ankylosis. Ankylosis causes loss of mobility of the spine. Ankylosing
spondylitis is also a systemic disease, meaning it can affect tissues throughout the body, not just
the spine. Accordingly, it can cause inflammation in and injury to other joints away from the
spine manifest as arthritis, as well as to other organs, such as the eyes, heart, lungs, and kidneys.
Ankylosing spondylitis shares many features with several other arthritis conditions, such
as psoriatic arthritis, reactive arthritis (formerly called Reiter's disease), and arthritis associated
with Crohn's disease and ulcerative colitis. Each of these arthritic conditions can cause disease
and inflammation in the spine, other joints, eyes, skin, mouth, and various organs. In view of
their similarities and tendency to cause inflammation of the spine, these medical conditions are
collectively referred to as "spondyloarthropathies." Ankylosing spondylitis is considered one of
the many rheumatic diseases because it can cause symptoms involving muscles and joints.

Morning stiffness is a very common complaint of patients with RA and is experienced as

soreness and restricted movement upon awakening. This feeling is generalized in distribution
and does not simply affect the joints. Although it is a form of pain, patients may not describe it
as such. (David S. Pisetsky, 2009)

The duration of morning stiffness is a good indicator of disease activity, and physicians
should record this value as part of the clinical assessment. Many patients take a hot shower to
relieve the sensation. The “gel phenomenon” stiffness and soreness that develops after a period
of immobility (e.g., sitting in a chair) is a related symptom. Morning stiffness is common
in rheumatoid arthritis (RA), an autoimmune disease that affects your joints. It may also be a
symptom of other joint conditions like:

• Osteoarthritis (OA), when cartilage covering the end of your bones wears away and the
bones rub together
 • Psoriatic arthritis, an inflammatory arthritis often linked to psoriasis, a condition that
causes red, patchy, scaly skin

• Ankylosing spondylitis, an inflammatory disease that can cause the bones in your spine to
grow together

Long-lasting morning stiffness usually means inflammation. Your immune

system attacks the synovium, the tissue lining your joints, and causes inflammation. It’s the
inflammation that causes RA symptoms like stiff, painful joints. Longer periods of morning
stiffness may mean your inflammation is higher or that your disease is more active. Morning
stiffness often affects small joints, like those in your hands, fingers, wrists, and toes. You may
wake up and feel like you can’t bend your fingers or make a fist. Morning stiffness can also
show up in your elbows, shoulders, neck, or other joints. (Susan Bernstein, 2020)

Yoga is a methodical effort toward self-perfection through developing the talent potential
on the physical, vital, mental, intellectual, and spiritual levels. And the most fundamental step
you can take toward expanding the limits of the consciousness is to gain mastery over the mind.
Therefore, yoga is an extraordinary spiritual science of self-development and self-realization that
shows us how to develop our full potential in our many-sided lives. It was first devised by the
rishis and sages of ancient India and has been maintained by a stream of living teachers ever
since, who have continually adapted this science to every generation. Yoga’s integrative
approach brings deep harmony and unshakable balance to body and mind in order to awaken our
latent capacity for a higher consciousness that is the true purpose of human evolution. The many
methods of yoga spans a vast range from physical postures to breathing practices and meditation,
all based upon a philosophy of consciousness and natural way of life.

Certain yoga poses, movements and breathing methods can help address posture and
mobility as well as potentially address the energetic layer (address fatigue, improve sleep) or
produce a calming effect on the nervous system which can help with such things as pain
management. Mindfulness or meditation practices such as awareness, visualization or other
methods of focus can also potentially help with pain management, change the pain experience,
and perhaps even reduce the chance that the genes associated with inflammation are expressed
(Kaliman et al, 2014).
 Yoga can be used as a valuable and beneficial complementary therapy to one’s current
medical treatment. With yoga education, supportive treatment as needed, and guidance, people
with AS can have active, meaningful, happy lives and relationships filled with vitality and
longevity.

Objectives of the Study

The objectives of the study are as follows

1. To assess the pre and post test level of the clinical variable morning stiffness among
ankylosing spondylitis patients in experimental group and control group.

2. The aim of the study is to investigate the effect of yoga training on functional level, disease
activity, spinal mobility, balance and quality of life in ankylosing spondylitis patients.

Statement of the Problem

The purpose of the study is to find out the effect of selected yogic practices on clinical
variable morning stiffness among ankylosing spondylitis.

Inclusion Criteria and Exclusion Criteria

Inclusion Criteria

1. Subjects of suspected ankylosing spondylitis belonging the age group between 18 to 40 yrs

2. Only subjects who know English, Hindi and Telugu language were included for the study.

3. Ankylosing spondylitis diagnosed subjects are included for this study.

4. Subjects who were willing to participate in the study

Exclusion Criteria

1. Subjects who are not willing to participate in the study.

2. Subjects who were diagnosed as ankylosing spondylitis with other medical disease like
cardiac disease, diabetes mellitus etc.
3. Subjects who underwent surgery for spine or lower limb.

4. Subjects who fail to complete the test

Ethical Consideration

The proposed study was conducted after the approval of the dissertation and ethics
committee of KIMS Hospital, Secunderabad, Telangana. Formal permission was obtained from
the medical officer of KIMS Hospital. Informed written consent was obtained from each
participant before starting the data collection.

Review of Literature

• Umair Khan et al., (2020) scrutinized yoga therapy for rheumatoid arthritis. As the
prevalence and incidence of rheumatoid arthritis continues to rise, and current
pharmaceutical interventions offered have been shown to elicit negative side effects, there
has been a recent shift in the use of supportive and therapeutic medical modalities. In
particular, functional treatments, like yoga therapy show great promise as a complement to
traditional medicine. In this review, we provide a brief overview of yoga therapy, present the
latest findings between the relationship of yoga therapy and Rheumatoid Arthritis, and
discuss the future direction of this promising field.

• Romy Lauche et al., (2019) observed yoga for osteoarthritis: a systematic review and meta-
analysis. This study aims to systematically review and summarize the efficacy and safety of
yoga for osteoarthritis. Primary outcomes were pain intensity, function, and quality of life;
secondary outcomes were mental health and safety. Risk of bias was assessed using the
Cochrane tool and quality of evidence through GRADE. Nine trials including 640 individuals
with mainly lower extremity osteoarthritis aged 50–80 years were identified, with 80.3%
female participants (median). Meta-analyses revealed very low–quality evidence for the
effects of yoga on pain (vs. exercise: standardized mean difference (SMD) = − 1.07; 95%CI
− 1.92, − 0.21; p = 0.01; vs. non-exercise: SMD = − 0.75; 95%CI − 1.18, − 0.31; p < 0.001),
physical function (vs. exercise: SMD = 0.80; 95%CI 0.36; 1.24; p < 0.001; vs. non-exercise:
SMD = 0.60; 95%CI 0.30, 0.98; p < 0.001), and stiffness (vs. exercise: SMD = − 0.92; 95%CI
 − 1.69, − 0.14; p = 0.008; vs. non-exercise: SMD = − 0.76; 95%CI − 1.26, − 0.26; p = 0.003)
in individuals with knee osteoarthritis. Effects were not robust against potential
methodological bias. No effects were found for quality of life, and depression, or for hand
osteoarthritis. Safety was rarely reported. The findings of this meta-analysis indicate that
yoga may be effective for improving pain, function, and stiffness in individuals with
osteoarthritis of the knee, compared to exercise and non-exercise control groups. Due to the
low methodological quality and potential risk of bias, only a weak recommendation can be
made at this time for the use of yoga in adults with osteoarthritis of the knee.

• Feinstein AB et al., (2018) examined yoga intervention for an adolescent with juvenile
idiopathic arthritis: a case study. Juvenile idiopathic arthritis (JIA) is a chronic rheumatic
disease associated with pain, stiffness, and psychosocial difficulties. The purpose of this case
study was to investigate the impact of a yoga intervention on pain and morning stiffness in an
adolescent female with JIA. A secondary aim was to assess the impact of this intervention on
self-efficacy, mindfulness, health-related quality of life, and disease activity. A 17-y-old
female with JIA participated in 3 yoga groups and home yoga practice with a digital video
disc. She engaged in daily self-monitoring of pain and stiffness and completed questionnaires
assessing psychosocial functioning and disease activity at pre- and postintervention, and
psychosocial functioning at 3-mo follow-up. Primary outcomes were evaluated using quasi-
experimental single-case design structure (ie, ABAB), with emphasis on the report of means.
Results suggested that yoga reduced pain intensity, stiffness intensity, and duration of
morning stiffness. Outcomes for disease activity also suggested improvements. Modest
changes were revealed on psychosocial outcome measures, however not consistently in the
direction of hypotheses. Anecdotal reports from the participant indicated acceptability of the
intervention and improvements in pain and stiffness attributed to engaging in the yoga
intervention. More research is warranted to further explore the impact of yoga for youth with
JIA as an adjunctive component of multidisciplinary treatment targeting pain, stiffness,
disease activity, and psychosocial factors.

• Singh Deepeshwar et al., (2018) analyzed the effect of yoga based lifestyle intervention on
patients with knee osteoarthritis: a randomized controlled trial. To investigate the effect of
integrated approach of yoga therapy (IAYT) intervention in individual with knee
Osteoarthritis. Sixty-six individual prediagnosed with knee osteoarthritis aged between 30
 and 75 years were randomized into two groups, i.e., Yoga (n = 31) and Control (n = 35).
Yoga group received IAYT intervention for 1 week at yoga center of S-VYASA whereas
Control group maintained their normal lifestyle. The Falls Efficacy Scale (FES), Handgrip
Strength test (left hand LHGS and right hand RHGS), Timed Up and Go Test (TUG), Sit-to-
Stand (STS), and right & left extension and flexion were measured on day 1 and day 7. There
were a significant reduction in TUG (p < 0.001), Right (p < 0.001), and Left Flexion (p <
0.001) whereas significant improvements in LHGS (p < 0.01), and right extension (p < 0.05)
& left extension (p < 0.001) from baseline in Yoga group. IAYT practice showed an
improvement in TUG, STS, HGS, and Goniometer test, which suggest improved muscular
strength, flexibility, and functional mobility.

Research Methodology

For the present study 60 ankylosing spondylitis patients between 18 - 40 years were
selected as the subjects from Rheumatology Department, KIMS Hospital, Secunderabad,
Telangana. All the subjects were assigned to Experimental group - I who underwent yoga
therapy consisting 30 subjects and Control group – II no practice consisting 30 subjects. The
experimental group practiced for twelve weeks for five days per weeks. The yogic practices
given to the experimental group for first week included Pavanamuktasana Series - Greeva
sanchalana (neck movements) stage 1,2,3,4, Mushtika Bandhana (hand clenching), Manibandha
naman (wrist bending), Manibandha chakra (wrist joint rotation), Kehuni naman (elbow
bending), Skanda chakra (shoulder socket rotation); Breathing Exercises - Hands in and hands
out breathing, Hands stretch breathing Horizontal, 135degree, vertical), Dog breathing, Rabbit
breathing, Shashank breathing; Asanas -Parivritta sukhasana, Shashankasana (pose of the moon
or hare pose), Marjari asana (cat stretch pose), Vyagrasana (tiger pose). The morning stiffness
was measured by ASDAS (Ankylosing Spondylitis Disease Activity Score) Pedro M Machado et
al., (2018 ).

Analysis and Results

 The data pertaining to the variables collected from the two groups before and after the
training period were statistically analyzed by using Analysis of Covariance (ANCOVA) to
determine the significant difference and tested at 0.05 level of significance. The following tables
illustrate the statistical result of the influence of yoga therapy on morning stiffness among
ankylosing spondylitis patients.

Table - I

Analysis of Covariance of pre-test, post -test and adjusted post-test on morning stiffness of
experimental and control groups

(Scores in Numbers)

Experimental Control
Group Group SV SS df MS Obtained F
I II
Pre Test

Mean 31.43 31.33 B 0.15 1 0.15

0.02
SD 3.00 3.09 W 558.03 58 9.62
Post Test

Mean 20.93 31.53 B 1685.4 1 1685.4

181.92*
SD 2.82 3.14 W 537.33 58 9.26
Adjusted Post Test
B 1692.90 1 1692.90
Mean 20.92 31.54 192.05*
W 502.44 57 8.81
Mean
10.5 0.2
Diff
* Significant at 0.05 level Table F-ratio at 0.05 level of confidence for 1 and 58 (df) =4.01, 1 and
57 (df) = 4.01

Table - II

Scheffe’s Post-Hoc Test F-Ratio of experimental and control groups on morning stiffness

(Scores in Numbers)
 Experimental Control Mean Required
Group I Group II difference C.I

20.92 31.55 10.63* 1.26

* Significant at .05 level

Figure - 1

Bar Diagram on Mean values of Morning Stiffness

(Scores in Numbers)

Results of Morning Stiffness

The analysis of covariance of morning stiffness data between pre-test and post-test of the
two groups have been presented in Table I. Table I shows the analysis of covariance of morning
stiffness. The pre-test means of experimental group and control group were 31.43 and
31.33respectively. Since the obtained F-ratio of 0.02 is lower than the table value, F-ratio of
4.01, the pre-test means were not significant at 0.05 level of confidence with the degrees of
freedom 1 and 58. The post test means of experimental group and control group were 20.93 and
31.53 respectively. The obtained F-ratio of 181.92 is seen to be higher than the table F-ratio of
4.01. Hence, the differences among the post-test means were significant at 0.05 level of
confidence with degrees of freedom 1 and 58. The adjusted post-test means of experimental
group and control group were 20.92 and 31.54 respectively. Since the obtained F-ratio of 192.05
is higher than the table F-ratio of 4.01 the adjusted post-test mean difference amount the two
groups were significant at 0.05 level of confidence with the degrees of freedom 1 and 57.
Scheffe’s post-hoc test was resorted-to, to find out the significance of ordered adjusted final
means difference among the groups. Table II shows the Scheffe’s post-hoc test results. The
ordered adjusted morning stiffness means, differences between means and Scheffe’s Post Hoc
test F-ratio of experimental group and control group were tested for significance against
Scheffe’s post-hoc test F ratio.

Conclusion

Based on the results obtained, the following conclusion was drawn: It was concluded that
Experimental group I yoga therapy was effective than the control group in improving the
morning stiffness among ankylosing spondylitis patients.

References

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3. Singh Deepeshwar, Monika Tanwar, Vijaya Kavuri and Rana B. Budhi. Effect of Yoga
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